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Objective: The authors sought to characterize the short-term risks of repeat self-harm and psychiatric hospital admission for deliberate self-harm patients discharged from emergency departments to the community, focusing on recognition of mental disorders in the emergency department. Method: A retrospective longitudinal cohort analysis of national Medicaid claims data was conducted of adults 21-64 years of age with deliberate self-harm who were discharged from emergency departments (N=5,567). Rates and adjusted risk ratios are presented of repeat self-harm visits and inpatient psychiatric admission during the 30 days following the initial emergency visit. Results: Approximately 9.7% of self-harm visits were followed by repeat self-harm visits and 13.6% by inpatient psychiatric admissions within 30 days after the initial emergency visit. The rate of repeat self-harm visits was inversely related to recognition of a mental disorder in the emergency department (adjusted risk ratio [ARR]=0.66, 95% 0=0.55-0.79) and directly related to recent diagnosis of anxiety disorders (ARR=1.56, 95% 0=1.30-1.86) or personality disorders (ARR=1.67,95% Cl=1.19-2.34). Recognition of a mental disorder in the emergency department was inversely related to repeat self-harm among patients with no recent mental disorder diagnosis (ARR=0.57, 95% 0=0.41-0.79); any recent mental disorder diagnosis (ARR=0.70, 95%=0.57-0.87); and depressive (ARR=0.71, 95% 0=0.54-0.94), bipolar (ARR=0.70, 95% 0=0.51-0.94), and substance use (ARR=0.71, 95% 0=0.53-0.96) disorder diagnoses. Recognition of a mental disorder was also inversely related to subsequent inpatient psychiatric admission (ARR=0.81, 95% 0=0.71-0.93). Conclusions: Adults who are discharged to the community after emergency visits for deliberate self-harm are at high short-term risk of repeat deliberate self-harm and hospital admission, although these risks may be attenuated by clinical recognition of a mental disorder in the emergency department. [ABSTRACT FROM AUTHOR]

Objective: This study attempted to estimate the relative risk of developing hyperlipidemia after treatment with antipsychotics in relation to no antipsychotic treatment. Method: A matched case-control analysis was performed with pharmacy and claims data from California Medicaid (Medi-Cal). Patients were excluded if they were treated for medical disorders or prescribed medications known to increase their risk of hyperlipidemia. Cases were ages 18 to 64 years with schizophrenia, major depression, bipolar disorder, or other affective psychoses and incident hyperlipidemia. Cases were matched to up to six control subjects by age, sex, race, and psychiatric diagnosis. Both groups were prescribed either no antipsychotic medication or had two or more prescriptions for one and only one antipsychotic medication during the 60 days prior to the first indication of hyperlipidemia (cases) or matched index date (controls) in the billing record. Conditional logistic regressions were used to derive odds ratios and 95% confidence intervals (95% Cls) of each antipsychotic medication in relation to no antipsychotic medication. Results: A total of 13,133 incident cases of hyperlipidemia were matched to 72,140 control subjects. As compared with no antipsychotic medication, treatment with clozapine (odds ratio: 1.82, 95% CI: 1.61-2.05), risperidone (odds ratio: 1.53, 95% CI: 1.43–1.64), quetiapine (odds ratio: 1.52, 95% CI: 1.40-I .65), olanzapine (odds ratio: 1.56, 95% CI: 1.47–1.67), ziprasidone (odds ratio: 1.40, 95% CI: 1.19–1.65), and first-generation antipsychotics (odds ratio: 1.26, 95% CI: 1.14–1.39), but not aripiprazole (odds ratio: 1.19, 95% CI: 0.94–1.52) was associated with a significant increase in risk of incident hyperlipidemia. Conclusions: These findings suggest that most commonly prescribed antipsychotic medications increase the risk of developing hyperlipidemia in patients with schizophrenia or mood disorders. [ABSTRACT FROM AUTHOR]

Objective: Continuation of antidepressant treatment for depression beyond the first months helps to consolidate treatment response and to reduce the risk of early relapse. The authors sought to characterize the rate and pattern of antidepressant discontinuation among adults initiating antidepressant treatment for depression. Method: Data were drawn from the household component of the Medical Expenditure Panel Survey for 1996-2001. Analysis was limited to data for adults age 18 years and older (N=829) who initiated antidepressant treatment for depression and who 1) discontinued treatment during the first 30 days of treatment, 2) completed the first 30 days of treatment and then discontinued treatment during the following 60 days, or 3) continued treatment for more than 90 days after treatment initiation. Results: A majority of the patients discontinued antidepressant therapy during the first 30 days (42.4%). Only 27.6% of the patients continued antidepressant therapy for more than 90 days. Antidepressant discontinuation during the first 30 days of treatment was significantly more common among Hispanics (53.8%) than non-Hispanics (41.3%); patients with fewer than 12 years of education (50.8%), compared with those with 12 or more years (39.3%); and patients with low family incomes (50.2%), compared with those with medium or high family incomes (38.6%). Patients were significantly more likely to continue anti-depressant treatment beyond 30 days if they received psychotherapy (68.0% versus 43.7%), completed 12 or more years of education (64.8% versus 52.0%), or had private health insurance (60.1% versus 50.8%). Among those who continued antidepressants beyond 30 days, antidepressant continuity during the subsequent 60 days was significantly associated with fair or poor pretreatment self-rated mental health and physical health, treatment with a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor, and psychotherapy. Conclusions: Early discontinuation of antidepressant therapy is widespread in the community treatment of depression, especially among socioeconomically disadvantaged patients. Provision of psychotherapy and selection of an appropriate antidepressant medication may reduce the risk of discontinuation during the first 3 months of antidepressant treatment for depression. [ABSTRACT FROM AUTHOR]

Objective: This study examined patterns of psychotropic medication use after the Sept. 11, 2001, terrorist attacks. Method: It drew from two large pharmacy data sets, one providing nationally representative aggregate projections for all U.S. prescriptions (156.9 million claims for psychotropic medications during the study period) and a second from the nation's largest pharmacy benefit management organization (36.4 million enrollees per month), 4.1% of whom had a prescription for a psychotropic medication during the study period. Analyses examined use of antidepressant, antipsychotic, anxiolytic, and hypnotic medications in the 12 weeks before and after Sept. 11, 2001, compared with the same weeks during 2000. Results: Nationally and in Washington, D.C., there was no evidence of an increase in overall prescriptions, new prescriptions, or daily doses for psychotropic medications. In New York City, there was an in- crease in the proportion of existing users with psychotropic dose increases in the weeks after the attacks (16.9% in 2001 versus 13.6% in 2000) but no significant increase in the rate of new psychotropic prescriptions. Conclusions: For most of the nation, the distress associated with the terrorist attacks was not accompanied by a commensurate increase in the use of psychotropic medications. In New York City, there was a statistically significant but modest increase in the proportion of individuals with dose increases in their psychotropic medications. [ABSTRACT FROM AUTHOR]

Objective: This study examined the relationship between utilization management techniques and psychiatrists' treatment plan modifications. Method: Nationally representative data on 1,843 patients treated by 615 psychiatrists participating in the American Psychiatric Institute for Research and Education's Practice Research Network were used to examine the demographic and clinical characteristics of patients whose care was subjected to utilization management and to assess the association between utilization management and psychiatrists' treatment plan modifications. Results: Approximately half of all patients had treatment that was subject to utilization management (52.6%). For the patients whose treatment was not subject to utilization management, 15.5% had their treatment plan changed compared to the 31.5% who were subject to utilization management. Overall, after adjustment for differences in patients, settings, and psychiatrist characteristics, the patients subject to utilization management were 2.6 times more likely to have their treatment changed than the patients who were not subject to utilization management. These patients were 3.7 times more likely to have their type of treatment changed and 2.3 times more likely to have their frequency or number of visits changed. Psychiatrists in individual practice settings and those with nonsalaried income sources were more likely to modify treatment decisions for their patients when subject to utilization management. Conclusions: The presence of utilization management is highly associated with changes in psychiatrists' treatment decisions. When compared to evidence-based treatment recommendations, these changes seem likely to result in less than optimal care. [ABSTRACT FROM AUTHOR]

Objective: This article reports recent trends in the use of outpatient psychotherapy in the United States. Method: Data from the household sections of the 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey were analyzed. Trends in the rate of psychotherapy use from these nationally representative samples are presented by age, sex, race/ethnicity, marital status, education, employment status, and income. Psychotherapy users are compared over time by provider specialty, concomitant psychotropic medication use, number of annual visits, and costs. In addition, trends in payment source and primary diagnosis are assessed for psychotherapy visits. Results: Between 1987 and 1997, there was no statistically significant change in the overall rate of psychotherapy use (3.2 per 100 persons in 1987 and 3.6 per 100 in 1997). However, significant increases were observed in psychotherapy use by adults aged 55-64 years and by unemployed adults. Among psychotherapy patients, there was a marked increase in the use of antidepressant medications (14.4% to 48.6%), mood stabilizers (5.3% to 14.5%), stimulants (1.9% to 6.4%), and psychotherapy provided by physicians (48.1% to 64.7%). A smaller proportion of patients made more than 20 psychotherapy visits in 1997 (10.3%) than in 1987 (15.7%). Over this period, psychotherapy visits for mood disorders became more common. In 1997, 9.7 million Americans spent $5.7 billion on outpatient psychotherapy. Conclusions: From 1987 to 1997, access to psychotherapy in the United States remained constant overall but was characterized by increased use by some socioeconomically disadvantaged groups. However, the number of visits per user markedly decreased during this period. Psychotherapy was increasingly administered by physicians and provided in conjunction with psychotropic medications. These changes occurred during a period of expansion in the number of available psychotropic medications and growth in managed... [ABSTRACT FROM AUTHOR]

Examines the prevalence, characteristics and impact of mental and general medical disabilities in the United States. Association of disabilities attributed to a mental condition with social and cognitive difficulties; Estimated number of Americans who reported that a mental condition contributes to their disability.

Attempts to determine the extent and pattern of blood serum monitoring of mood stabilizers in Medicaid patients with bipolar disorder. Demographic and service use characteristics; Likelihood of therapeutic drug monitoring and case management services; Likelihood that lithium users will receive the recommended serum level test.

Examines trends in the composition and duration of visits to psychiatrists in office-based psychiatric practice. Use of physician-reported data from the 1985 and 1995 National Ambulatory Medical Care Surveys; Secular changes in visit characteristics; Factors affecting changes in practice style.

Background: In addition to symptoms, DSM-IV criteria for major depression require clinical significance, operationalized via reports of receipt of care or interference in functioning. The authors examined whether this confounding of symptoms with receipt of care and/or impairment affected racial differences in rates of major depression in the community. Method: Analysis of data from the 1999 National Health Interview Survey for a nationally representative community sample of 30,801 adults administered the depression module of the Composite International Diagnostic Interview-Short Form. Results: There were no differences between African American subjects and white/other subjects when diagnosis was based solely on symptoms. Symptomatic African American individuals were less likely to endorse either receipt of care or interference in functioning, so that the clinical significance criterion served to reduce their rates of DSM-IV diagnosis. Conclusions: The clinical significance criterion underestimates of the rate of depression for African American individuals relative to white/other subjects, which may in turn underestimate their need for services. [ABSTRACT FROM AUTHOR]

Presents a study which examines the effect of self-reported anxiety on the days persons with various general medical conditions spend in bed owing to disability. Analysis of the data collected; Method used in this study; Results of the study; Discussions on the results.

Objective: The authors investigated recent trends in the use of outpatient psychotherapy in the United States. Method: Service use data from two representative surveys of the U.S. general population, the 1998 (N=22,953) and 2007 (N=29,370) Medical Expenditure Panel Surveys, were analyzed, focusing on individuals who made more than one outpatient psychotherapy visit during that calendar year. The authors computed rates of any psychotherapy use; percentages of persons treated for mental health conditions with only psychotherapy, only psychotropic medication, or their combination; the mean number of psychotherapy visits of persons receiving psychotherapy; and psychotherapy expenditures. Results: The percentage of persons using outpatient psychotherapy was 3.37% in 1998 and 3.18% in 2007 (adjusted odds ratio=0.95, 95% CI=0.82-1.09). Among individuals receiving outpatient mental health care, use of only psychotherapy (15.9% and 10.5% in 1998 and 2007, respectively; adjusted odds ratio=0.66, 95% CI=0.48-0.90) as well as psychotherapy and psychotropic medication together (40.0% and 32.1%; adjusted odds ratio=0.73, 95% CI=0.59-0.90) declined while use of only psychotropic medication increased (44.1% and 57.4%; adjusted odds ratio=1.63, 95% CI=1.32-2.00). Declines occurred in annual psychotherapy visits per psychotherapy patient (mean values, 9.7 and 7.9; adjusted β=-1.53, p<0.0001), mean expenditure per psychotherapy visit ($122.80 and $94.59; β=28.21, p<0.0001), and total national psychotherapy expenditures ($10.94 and $7.17 billion; z=2.61, p=0.009). Conclusions: During the decade from 1998 to 2007, the percentage of the general population who used psychotherapy remained stable. Over the same period, however, psychotherapy assumed a less prominent role in outpatient mental health care as a large and increasing proportion of mental health outpatients received psychotropic medication without psychotherapy. [ABSTRACT FROM AUTHOR]

A response by Mark Olfson and his colleagues to a letter to the editor about their article confounding by indication of antipsychotics in patient with hyperlipidemia in the 2006 issue is presented.

Objective: The authors examined national trends from 1990 to 2000 in the utilization of community hospital inpatient services by young people (5-20 years of age) with intentional self-inflicted injuries. Method: Discharge abstracts from a nationally representative sample of community hospitals were analyzed, with a focus on youth discharges (N=10,831) with a di- agnosis of intentional self-inflicted injury (ICD-9-CM: E950-E959). Census data were used to derive national population-based rates of self-inflicted injuries requiring in- patient treatment. Overall population- based trends in hospitalizations for self-inflicted injury were calculated and stratified by gender and age. Among youths hospitalized with a self-inflicted injury, trends were also calculated for length of stay, in- patient costs, method of injury, and associated mental disorder diagnoses. Results: The annual hospitalization rate of youths with self-inflicted injuries declined from 49.1 per 100,000 in 1990 to 44.9 per 100,000 in 2000, and the mean length of inpatient stay significantly declined from 3.6 days to 2.7 days. Among the hospitalized patients, there were in- creases in the rate of cutting (4.3% to 13.2%) and ingestion of acetaminophen (22.1% to 26.9%), antidepressants (10.0% to 14.0%), and opiates (2.3% to 3.3%) as a cause of injury, whereas there were decreases in the ingestion of salicylates (14.9% to 10.2%) and barbiturates (1.5% to 0.7%), There were significant increases in the proportion of subjects with primary mental disorder discharge diagnoses of depressive disorder (29.2% to 46.0%), bipolar disorder (1.3% to 8.2%), and substance use disorder (5.4% to 10.7%) and significant decreases in the rate of adjustment disorders (22.2% to 11.4%) and non-mental disorders (31.9% to 13.6%). After excluding cutting, which may be more closely related to self-mutilation than suicidal self-injury, the annual hospitalization rate of youths with self-inflicted injuries declined from 47.2 per 100,000 in 1990 to 39.4 per 100,000 in 2000. Conclusions: Over the decade of study, young people admitted to community hospitals with self-inflicted injuries tended to have more severe psychiatric diagnoses and to be treated during shorter inpatient stays. These trends suggest that the role of youth inpatient care has narrowed, becoming focused on those with severe psychiatric disorders. [ABSTRACT FROM AUTHOR]

Objective: Nationally representative descriptive data were presented regarding recent trends in the outpatient treatment of attention deficit hyperactivity disorder (ADHD) in children. Method: Service use data were analyzed in children ages 3 to 18 years from two nationally representative surveys of the U.S. general population, the 1987 National Medical Expenditure Survey, and the 1997 Medical Expenditure Panel Survey. Trends in the rates of treatment for ADHD were presented by age, gender, race, family income, and health insurance status. Trends in ADHD treatment were also determined by annual numbers of visits, use of pharmacotherapies, and types of health care professionals. Results: The rate of outpatient treatment for ADHD increased from 0.9 per 100 children in 1987 to 3.4 per 100 children in 1997. Significant increases in the rates of treatment for ADHD were evident across nearly all sociodemographic groups, with the largest increases among children from poor, near-poor, and low-income families and children ages 12 to 18. Among children who received treatment for ADHD, there was a significant decrease in the number of treatment visits but an increase in the number of stimulant prescriptions between 1987 and 1997. Conclusions: During the decade, there was a marked and broad expansion in access to treatment of children with ADHD but a decline in intensity of treatment, as measured by number of visits. These changes occurred during a period of expanding access to special education services, growth of managed behavioral healthcare, and increased public acceptance of effective psychotropic medications. [ABSTRACT FROM AUTHOR]

Examines the changes in the prescription patterns for medications in the treatment of bipolar disorder. Predictors of medication prescription; Popularity of antidepressants in bipolar disorder treatment; Information on the advances in the range of mood stabilizers.

Characterizes psychiatric practice by reporting the findings of the `1996 National Survey of Psychiatric Practice.' Contents of the survey; Methods used to conduct studies; What results of study indicate.

Presents reply to a letter about ethnic differences, published in "The American Journal of Psychiatry" as of May 2004.